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What is the nurse's priority when a client experiences a seizure?
- A. Restrain the client.
- B. Protect the airway.
- C. Administer oxygen.
- D. Record the duration.
Correct Answer: B
Rationale: Protecting the airway is the priority to ensure oxygenation during a seizure.
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The nurse should assess the client with Ménière'sdisease for the intended outcomes of which of the following medications that are commonly used to manage the disease? Select all that apply.
- A. Antihistamines.
- B. Antiemetics.
- C. Diuretics.
- D. Non-steroidal anti-inflammatory drugs (NSAIDs).
- E. Antipyretics.
Correct Answer: A,B,C
Rationale: Common medications for Ménière'sdisease include antihistamines (e.g., meclizine) to reduce vertigo, antiemetics to control nausea, and diuretics to reduce inner ear fluid, all aimed at symptom management.
A client with terminal cancer expresses fear of dying alone. The nurse's most therapeutic response is:
- A. You won't be alone; we'll ensure someone is with you.
- B. Everyone dies alone, but it's not something to fear.
- C. Let's focus on keeping you comfortable instead.
- D. Have you considered spiritual counseling?
Correct Answer: A
Rationale: Assuring the client that someone will be present addresses their fear directly, providing emotional reassurance and support.
A client is being treated for deep vein thrombosis (DVT) in the left femoral artery. The physician has ordered 60 mg of enoxaparin (Lovenox) subcutaneously. Before administering the drug, the nurse checks the client’s laboratory results, noted below. Based on these results, the nurse should:
- A. Assess the client for bleeding.
- B. Administer the medication.
- C. Inform the physician.
- D. Withhold the dose of Lovenox.
Correct Answer: D
Rationale: Based on the laboratory fi ndings, prothrombin time and INR are at acceptable anticoagulation levels for the treatment of DVT. However, the platelets are below the acceptable level. Clients taking enoxaparin are at risk for thrombocytopenia. Because of the low platelet level, the nurse should withhold the enoxaparin, assess the client for bleeding, and then contact the physician.
The nurse is caring for a child who is immunocompromised and diagnosed with varicella. The nurse should request a prescription from the physician for which medication?
- A. amoxicillin-clavulanate
- B. acyclovir
- C. doxycycline
- D. azithromycin
Correct Answer: B
Rationale: Acyclovir is an antiviral medication used to treat varicella (chickenpox) in immunocompromised patients to reduce severity and complications. Choice A (amoxicillin-clavulanate) and Choice D (azithromycin) are antibiotics, ineffective against viral infections. Choice C (doxycycline) is an antibiotic and not suitable for children under 8 due to the risk of tooth discoloration.
The nurse is completing a health assessment of a 42-year-old female with suspected Graves' disease. The nurse should assess this client for:
- A. Anorexia.
- B. Tachycardia.
- C. Weight gain.
- D. Cold skin.
Correct Answer: B
Rationale: Graves' disease, the most common type of thyrotoxicosis, is a state of hypermetabolism. The increased metabolic rate generates heat and produces tachycardia and fine muscle tremors. Anorexia is associated with hypothyroidism. Loss of weight, despite a good appetite and adequate caloric intake, is a common feature of hyperthyroidism. Cold skin is associated with hypothyroidism.